kap and msd variation in interventional...
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KAP and MSD variation in interventional cardiology
Jukka Järvinen Medical physicist
Turku university hospital
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Content
IC procedures KAP
• Few words on
basics
Data science
• Data mining for
procedure
difficulty levels
Skin doses
• Gafchromic
film MSDs and
erythema
risks in
Finland
• Alert Levels
• Dose variation
Skin dose
algorithms
• Skin dose
estimation
software and
their accuracy
• DRLs in Finland
and measured
EU KAP
• Dose variation
and ideas what
to do about it
• ICRP
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Interventional cardiology
• Team work between cardiologist and
2-3 nurses
• Patient is imaged during a procedure
from various projections with
fluoroscopy and often also cine
• Many clinical practices affect the often
instantaneous choices on how and
when to obtain necessary diagnostic
information
Typical Finnish exposures
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Most Dose-heavy procedures in Finland
Finnish DRLs
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And the same in the EU level
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Dose variation in Finland
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Dose variation in the EU PCI
TAVI
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Parameters and Practices
Procedure difficulty
Many possible parameters depending on the procedure
Optimization
Imaging protocols
FL time
Cine
Collimation
Projections
Zoom
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How to set difficulty levels?
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Dose monitoring software
DoseWatch, Radimetrics and many others available
Angiospecific parameters
Exportation of data
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Procedure registries
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Patient demographic data
Weight
Height
Age
Gender
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Dose prediction
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Dose prediction
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Maximum Skin Doses and Erythema Risks
There is a risk but how big is it?
How to communicate it?
How to implement good practices?
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CA PCI PI CRT AVNRT Atrial Fibrillation
TAVI
N 87 50 41 10 14 6 45 Mean Gafchromic film MSD (mGy)
116.15 437.08 96.34 121.76 158.74 210.55 623.81
Mean KAP (Gycm2)
26.67 95.86 5.45 31.07 7.85 20.48 64.66
Mean Air kerma (mGy)
479.63 1949.77 32.97 395.95 52.22 497.73 853.65
Max MSD (mGy)
377.27 941.68 187.16 235.98 415.35 322.99 4158.8
MSD standard deviation
91.97 589.86 62.90 98.00 154.07 104.86 823.93
Dose variation in Gafchromic Film Measurements
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Dose variation in Gafchromic Film Measurements
CA PCI PI CRT AVNRT Atrial Fibrillation
TAVI
N 87 50 41 10 14 6 45 Mean Gafchromic film MSD (mGy)
116.15 437.08 96.34 121.76 158.74 210.55 623.81
Mean KAP (Gycm2)
26.67 95.86 5.45 31.07 7.85 20.48 64.66
Mean Air kerma (mGy)
479.63 1949.77 32.97 395.95 52.22 497.73 853.65
Max MSD (mGy)
377.27 941.68 187.16 235.98 415.35 322.99 4158.8
MSD standard deviation
91.97 589.86 62.90 98.00 154.07 104.86 823.93
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What causes this variation?
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What causes this variation?
Use of projections
Patient size
Imaging protocols
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Alert Levels
• For 2 Gy MSD to be exceeded in TAVI
• 200 000 mGycm2 KAP
• Or
• 2 Gy air kerma
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Skin dose algorithms
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Rough outline on how they work
• Estimation of patient size and location
• Realtime data collection of projections
and irradiations
• Estimation of entry points and
summing skin doses
• DoseWatch, DoseWise, CareMonitor,
Dose tracking system..
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Software Comparisons
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Validation?
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Thank you!
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References
• Contemporary Radiation Doses in Interventional Cardiology: a Nationwide Study of Patient Doses in Finland. Järvinen J, Sierpowska J, Siiskonen T, Järvinen H, Kiviniemi T, Rissanen T, Matikka H, Niskanen E, Hurme S, Larjava HRS, Mäkela TJ, Strengell S, Eskola M, Parviainen T, Hallinen E, Pirinen M, Kivelä A, Teräs M. Radiation Protection Dosimetry (2019): 1-11.
• Establishing the European diagnostic reference levels for interventional cardiology. Siiskonen T, Ciraj-Bjelac O, Dabin J, Diklic A, Domienik-Andrzejewska J, Farah J, Fernandez JM, Gallagher A, Hourdakis CJ, Jurkovic S, Järvinen H, Järvinen J, Knezevic, Koukorova C, Maccia C, Majer M, Malchair F, Riccardi L, Rizk C, Sanchez R, Sandborg M, Sans Merce M, Segota D, Sierpowska J, Simantirakis G, Sukupova L, Thrapsanioti Z, Vano E. Physica Medica (2018) 54: 42-48.
• Exhaustive feature selection for predicting KAP radiation dose in coronary angiographies and percutaneous coronary interventions. Suomi V+, Järvinen J+, Kiviniemi T, Ylitalo A and Pietilä M. Submitted to Medical Physics in May 2019.
• Contemporary Radiation Doses in Interventional Cardiology: a Nationwide Study of Maximum Skin Doses in Finland. Järvinen J, Sierpowska J, Siiskonen T, Järvinen H, Kiviniemi T, Rissanen T, Matikka H, Niskanen E, Hurme S, Larjava HRS, Mäkela TJ, Strengell S, Eskola M, Parviainen T, Hallinen E, Pirinen M, Kivelä A, Teräs M. Submitted to Radiation Protection Dosimetry in May 2019.
• J. A. Crowhurst, M. Whitby, M. Savage, D. Murdoch, B. Robinson, E. Shaw, N. Gaikwad, R. Saireddy, K. Hay, and D. L. Walters. Factors contributing to radiation dose for patients and operators during diagnostic cardiac angiography, Journal of medical radiation sciences 66, 20{29 (2019).
• R. Padovani, G. Bernardi, M. R. Malisan, E. Vano, G. Morocutti, and P. M. Fioretti. Patient dose related to the complexity of interventional cardiology procedures, Radiation protection dosimetry 94, 189{192 (2001).
• A. Peterzol, E. Quai, R. Padovani, G. Bernardi, C. Kotre, and A. Dowling, Reference levels in PTCA as a function of procedure complexity, Radiation protection dosimetry 117, 54{58 (2005).